Endoscopic Retrograde Biliary Drainage Causes Intra-Abdominal Abscess in Pancreaticoduodenectomy Patients: An Important But Neglected Risk Factor

  • Jin-Ming Wu
  • Te-Wei Ho
  • Hung-Hsuan Yen
  • Chien-Hui Wu
  • Ting-Chun Kuo
  • Ching-Yao Yang
  • Yu-Wen TienEmail author
Pancreatic Tumors



Patients with periampullary cancer frequently suffer obstructive jaundice and commonly require preoperative biliary drainage (PBD) for relief and to avoid related complications. Although research has established a correlation between PBD and surgical wound infection, the impact of PBD on major infectious complications (intra-abdominal abscess [IAA]) and overall mortality remains debatable. We hypothesized that PBD could lead to IAA and mortality, and evaluated their correlation in patients undergoing pancreaticoduodenectomy (PD).


We enrolled patients undergoing PD at an Asian academic medical center between 2007 and 2016. The types of PBD included endoscopic retrograde biliary drainage (ERBD) and percutaneous transhepatic cholangiography and drainage (PTCD). The primary outcome was IAA, defined as the presence of pus or infected fluid inside the abdominal cavity and with documented infectious pathogens.


There was one (0.1%) 30-day mortality and eight (0.9%) 90-day mortalities among 899 consecutive patients examined. More than one-quarter of patients had PBD (n = 237, 26.4%; 165 ERBD, 72 PTCD). In the ERBD, PTCD, and non-PBD groups, the IAA rates were 37.0%, 16.7%, and 10.6%, respectively. On multivariate analysis, ERBD (odds ratio 3.67; 95% confidence interval 2.22–6.06; p < 0.001) was the only significant factor associated with IAA. No significant factor was found to analyze variables associated with mortality.


ERBD, but not PTCD, is associated with an increased risk of IAA in patients undergoing PD, which suggests that ERBD should be avoided whenever possible to prevent IAA. Further randomized clinical trials should be conducted to validate this relationship.



This study was supported by Grant Number 107-2634-F-002-015 from the Ministry of Science and Technology, Taiwan, which had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.


This work was submitted as an original article, and is not based on a previous communication to a society or meeting.

Supplementary material

10434_2019_7189_MOESM1_ESM.docx (24 kb)
Supplementary material 1 (DOCX 23 kb)


  1. 1.
    Fang Y, Gurusamy KS, Wang Q, et al. Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice. Br J Surg. 2013;100(12):1589–1596.CrossRefGoogle Scholar
  2. 2.
    Lai EC, Chu KM, Lo CY, et al. Surgery for malignant obstructive jaundice: analysis of mortality. Surgery. 1992;112(5):891–896.Google Scholar
  3. 3.
    Dixon JM, Armstrong CP, Duffy SW, Davies GC. Factors affecting morbidity and mortality after surgery for obstructive jaundice: a review of 373 patients. Gut. 1983;24(9):845–852.CrossRefGoogle Scholar
  4. 4.
    Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg. 2001;234(1):47–55.CrossRefGoogle Scholar
  5. 5.
    van der Gaag NA, Rauws EAJ, van Eijck CHJ, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362(2):129–137.CrossRefGoogle Scholar
  6. 6.
    Jagannath P, Dhir V, Shirikhande S, Shah RC, Mullerpatan P, Mohandas KM. Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg. 2005;92(3):356–361.CrossRefGoogle Scholar
  7. 7.
    Limongelli P, Pai M, Bansi D, et al. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery. 2007;142(3):313–318.CrossRefGoogle Scholar
  8. 8.
    Ng ZQ, Suthananthan AE, Rao S. Effect of preoperative biliary stenting on post-operative infectious complications in pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg. 2017;21(4):212–216.CrossRefGoogle Scholar
  9. 9.
    Costi R, De Pastena M, Malleo G, et al. Poor results of pancreatoduodenectomy in high-risk patients with endoscopic stent and bile colonization are associated with E coli, diabetes and advanced age. J Gastrointest Surg. 2016;20(7):1359–1367.CrossRefGoogle Scholar
  10. 10.
    Augenstein VA, Reuter NP, Bower MR, McMasters KM, Scoggins CR, Martin RC. Bile cultures: a guide to infectious complications after pancreaticoduodenectomy. J Surg Oncol. 2010;102(5):478–481.CrossRefGoogle Scholar
  11. 11.
    Wu JM, Kuo TC, Yang CY, et al. Resolution of diabetes after pancreaticoduodenectomy in patients with and without pancreatic ductal cell adenocarcinoma. Ann Surg Oncol. 2013;20(1):242–249.CrossRefGoogle Scholar
  12. 12.
    Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173(6):676–682.CrossRefGoogle Scholar
  13. 13.
    Pancreatric Section, British Society of Gastroenterology, Pancreatic Society of Great Britain and Ireland, Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, Royal College of Pathologists, Special Interest Group for Gastro-Intestinal Radiology. Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut. 2005;54 Suppl 5:v1–16.Google Scholar
  14. 14.
    Glenn F, Evans JA, Mujahed Z, Thorbjarnarson B. Percutaneous transhepatic cholangiography. Ann Surg. 1962;156:451–462.CrossRefGoogle Scholar
  15. 15.
    Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584–591.CrossRefGoogle Scholar
  16. 16.
    Yokoe M, Takada T, Strasberg SM, et al. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2013;20(1):35–46.CrossRefGoogle Scholar
  17. 17.
    Song TJ, Lee JH, Lee SS, et al. Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection. Gastrointest Endosc. 2016;84(5):814–821.CrossRefGoogle Scholar
  18. 18.
    Tol JA, van Hooft JE, Timmer R, et al. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut. 2016;65(12):1981–1987.CrossRefGoogle Scholar
  19. 19.
    Fernandez-del Castillo C, Morales-Oyarvide V, McGrath D, et al. Evolution of the Whipple procedure at the Massachusetts General Hospital. Surgery. 2012;152(3 Suppl 1):S56–S63.CrossRefGoogle Scholar
  20. 20.
    Povoski SP, Karpeh MS, Conlon KC, Blumgart LH, Brennan MF. Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointest Surg. 1999;3(5):496–505.CrossRefGoogle Scholar
  21. 21.
    Hodul P, Creech S, Pickleman J, Aranha GV. The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy. Am J Surg. 2003;186(5):420–425.CrossRefGoogle Scholar
  22. 22.
    Sahora K, Morales-Oyarvide V, Ferrone C, et al. Preoperative biliary drainage does not increase major complications in pancreaticoduodenectomy: a large single center experience from the Massachusetts General Hospital. J Hepatobiliary Pancreat Sci. 2016;23(3):181–187.CrossRefGoogle Scholar
  23. 23.
    Fong ZV, McMillan MT, Marchegiani G, et al. Discordance Between Perioperative Antibiotic Prophylaxis and Wound Infection Cultures in Patients Undergoing Pancreaticoduodenectomy. Jama Surg. 2016;151(5):432–439.CrossRefGoogle Scholar
  24. 24.
    Iacono C, Ruzzenente A, Campagnaro T, Bortolasi L, Valdegamberi A, Guglielmi A. Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks. Ann Surg. 2013;257(2):191–204.CrossRefGoogle Scholar
  25. 25.
    Sugiura T, Mizuno T, Okamura Y, et al. Impact of bacterial contamination of the abdominal cavity during pancreaticoduodenectomy on surgical-site infection. Br J Surg. 2015;102(12):1561–1566.CrossRefGoogle Scholar
  26. 26.
    Povoski SP, Karpeh MS, Jr., Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg. 1999;230(2):131–142.CrossRefGoogle Scholar
  27. 27.
    Garcea G, Chee W, Ong SL, Maddern GJ. Preoperative biliary drainage for distal obstruction the case against revisited. Pancreas. 2010;39(2):119–126.CrossRefGoogle Scholar
  28. 28.
    Wu CH, Ho TW, Wu JM, et al. Preoperative biliary drainage associated with biliary stricture after pancreaticoduodenectomy: a population-based study. J Hepatobiliary Pancreat Sci. 2018;25(6):308–318.CrossRefGoogle Scholar
  29. 29.
    Ding X, Zhang F, Wang Y. Risk factors for post-ERCP pancreatitis: A systematic review and meta-analysis. Surgeon. 2015;13(4):218–229.CrossRefGoogle Scholar
  30. 30.
    Al Mahjoub A, Menahem B, Fohlen A, et al. Preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma: is percutaneous transhepatic biliary drainage safer and more effective than endoscopic biliary drainage? A meta-analysis. J Vasc Interv Radiol. 2017;28(4):576–582.CrossRefGoogle Scholar
  31. 31.
    Komaya K, Ebata T, Yokoyama Y, et al. Verification of the oncologic inferiority of percutaneous biliary drainage to endoscopic drainage: a propensity score matching analysis of resectable perihilar cholangiocarcinoma. Surgery. 2017;161(2):394–404.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Jin-Ming Wu
    • 1
  • Te-Wei Ho
    • 1
  • Hung-Hsuan Yen
    • 1
  • Chien-Hui Wu
    • 1
  • Ting-Chun Kuo
    • 1
  • Ching-Yao Yang
    • 1
  • Yu-Wen Tien
    • 1
    Email author
  1. 1.Department of SurgeryNational Taiwan University Hospital and College of Medicine, National Taiwan UniversityTaipeiTaiwan

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